A new kid on the block: the role of physician associates
Editor – You called attention to the possibility of using physician associates (PAs) as one part of the solution to the insufficient number of emergency medicine trainees (Clin Med June 2014 pp 219–20). In the USA, where the profession has been established for 45 years, more than 10% of all US PAs practise emergency medicine and 68% of teaching hospitals employ PAs in the emergency department.1 Although the PA profession is in its infancy in the UK, emergency medicine is one of the most common specialties for British PAs.
In the spring of 2014, we conducted the fourth annual census of British PAs. An online survey link was sent to all PAs who have graduated from one of the recognised PA programmes, all members of the UK Association of PAs, all registrants on the PA Managed Voluntary Register and all known American- or Canadian-trained PAs in the country. In total, 134 (70.2%) responded out of 191 PAs believed to be living in the UK and eligible to practice as a PA.
Of all the PAs surveyed, 17 (12.7%) indicated that they practise emergency medicine. The median number of hours per week worked by PAs in emergency medicine was 37.5 and the median pay was £35,000 per annum. Emergency medicine PAs had a median of 2-years’ experience as a PA and just over 1 year of service in their current post. Two USA-trained PAs had more experience, with one working as a PA for 25 years and one for almost 6 years.
Self-report of scope of practice by PAs reveals substantial variability. All (100.0%) respondents reported performing history taking, physical examinations and patient education. Eight of the PAs regularly perform psychiatric assessments (47.1%). All PAs perform minor procedures, such as cannulation, whereas a minority perform procedures which are either more invasive or require further training to achieve proficiency (Table 1). The most invasive procedures were, in general, performed by the PAs with the most clinical experience (data not shown).
The number of PAs practising emergency medicine is still small. However, the number of UK-trained PAs in emergency medicine is growing. Between 2011 and 2014, the number of British-trained PAs in emergency medicine has increased from 6 to 13,2 despite the closure of two of the four programmes educating PAs during this time frame. As of July 2014, several universities are opening new PA programmes and existing programmes are expanding their intake of students. From a nadir of 36 entrants in 2012, there should be at least 150 students entering PA education programmes in 2015. As emergency medicine is one of the most popular specialties for UK-trained PAs, the number of PAs available to practice in accident and emergency should continue to grow.
The data show that most PAs in the UK are not yet performing more invasive clinical procedures used in emergency medicine. This is consistent with the experience of PAs in the USA and is related to their relative inexperience in emergency medicine (1–2 years in post). PA practice rests on a concept of ‘negotiated performance autonomy’ in which doctors provide their PAs with training for increasing skills over time and allow the PA to perform these duties autonomously once the PA has demonstrated competence to the doctor's satisfaction.3 As not all PAs are equally skilled at all tasks, the delegation of autonomy to the PA is granted by the doctor on an individual basis over time. It is also possible that the unresolved legal status of PAs is causing uncertainty among doctors about whether or not they are allowed to delegate these more invasive tasks to PAs.4 If the regulatory issues are resolved and PAs continue to gain experience in emergency care, evidence from the USA suggests that PAs will be able to increase their contribution to the emergency medical team.5
The NHS desperately needs to evaluate new methods for delivering emergency care. The short postgraduate educational pipeline (2 years) for PAs, their generalist training and their ability to expand their skill set over time should make the government seriously consider regulating these professionals and expanding the number of PAs in training.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2014 Royal College of Physicians
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